june 2016 version 1 - kem hospital · 5. bone and joint infections 24 6. skin and soft tissue...
TRANSCRIPT
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June 2016
Version 1.2
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Supported by :
Director (ME & MH)
Dean Seth G.S Medical College & K.E.M Hospital
Dean T.N Medical College and B.Y.L Nair Charitable Hospital
Dean L.T.M Medical College & L.T.M.G.H
Contributors
Heads of Departments of Municipal Medical Colleges or their designates
from various disciplines such as Cardiology, Chest Medicine, CVTS,
Dermatology, E.N.T, Gastroenterology, G.I surgery, General Medicine,
General Surgery, Microbiology, Neonatology, Nephrology, Neurology,
Neurosurgery, Obstetrics and Gynaecology, Ophthalmology,
Orthopaedics, Paediatrics, Pediatrics, Surgery, Pharmacology and
Therapeutics, Plastic Surgery, Urology.
Disclaimer
These guidelines have been prepared by consensus based on standard
practices, published evidence, updated information, available data and
individual experience of the experts. These guidelines are not exhaustive
by themselves. Medicine is an ever changing science and users of this
guideline are encouraged to refer to latest information. The final decision
on the choice and use of antimicrobials rests with the treating clinician.
Next Review : June 2018/19
This document is the property of M.C.G.M. Making copies without written
permission is prohibited.
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A
CONTENTS
A. List of abbreviations 4
B. Guidelines for antimicrobial therapy and / or prophylaxis
of common infection
1. Respiratory Tract Infections 5
2. CNS Infections 8
3. ENT infections 11
4. Ophthalmic infections 16
5. Bone And Joint Infections 24
6. Skin and soft tissue infections 28
7. CVS Infections 36
8. Intra-abdominal infections 38
9. Infections of Urinary Tract 44
10. Plastic surgery and burns 46
11. Infections in Obstetrics and Gynaecology 48
12. Pediatric infections 51
13. acute febrile illness 59
14. PRE – OPERATIVE PROPHYLAXIS/THERAPY 60
15. NEONATAL INFECTIONS : ANTIBIOTIC POLICY 73
16. Dental Guidelines 85
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1. Respiratory Tract Infections
Sr. No.
Conditions/ Expected
pathogens Revised MCGM recommendations
1. Acute pharyngitis Majority
viral, Suspect bacterial –
Grp A Streptococci
None indicated in viral infections Amoxycillin 500 mg PO TDS Or Azithromycin 500 mg PO OD
Duration: 5- 7 days Alternative options Doxycycline 100 mg BD Or
Cefuroxime axetil 500 mg BD
2. Acute bronchitis Viral – ILI
OPD patients Oseltamivir 75 mg PO BD
Duration: 5 days For pregnant women in epidemic setting with pharyngitis
and for severely ill patients with ARDS Oseltamivir 150 mg PO BD Duration: 5 days
3. Acute bacterial
exacerbation of COPD Most
likely -Atypical bacterial
pathogens and viruses Occasional -Streptococci, Hemophilus spp, Moraxella
Co-amoxiclav 625 mg PO TDS Duration:7 days Alternatives Azithromycin 500 mg oral OD × 3 days
Or Doxycycline* 100 mg PO BD Or Cefuroxime axetil* 500 mg PO BD
*Duration: 5-7 days
Fluoroquinolones not to be used in outpatient settings
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4.
Community Acquired Pneumonia S. pneumoniae,,Legionella,Ente
robacteriaceae, Viral (high
risk) (S. aureus also mentioned in NG)
OPD patients Coamoxyclav 625 mg TDS Duration: 7 days +/- Azithromycin 500 mg OD
Duration: 5 days
IPD patients Ceftriaxone 1 gm IV BD Or Co-amoxiclav 1.2 gm IV TDS
Duration - 7 days +
Azithromycin 500 mg IVOD Duration - 5 days In
epidemic settings: Oseltamivir 75 mg PO
BD Duration: 5 days
Remarks: If no response in 72 hrs, then upgrade as per Culture and
sensitivity report
5. Nosocomial pneumonia
(VAP)
Gram negative Bacilli, E.coli, Klebsiella
,Enterobacter, P. aeruginosa
Empiric therapy:
Piperacillin-Tazobactam 4.5 gm IV TDS
+/- Amikacin 500 mg IV OD
Remarks:
If no response in 72 hrs, then upgrade as per Culture and
sensitivity report
6 Pneumonia in transplant
recipients S. pneumoniae, H. influenzae
Legionella
Piperacillin + tazobactam 4.5 gm IV QDS Or Meropenem 1 gm IV TDS
Or Ceftazidime 1 gm IV TDS Duration: 14 days (with
renal correction)
Remarks: If no response in 72 hrs, then upgrade as per Culture and
sensitivity report If Pneumocystis jiroveci pneumonia is suspected add, Trimethoprim- Sulfamethaxazole 960 mg 2 tablets TDS
Duration: 10-14 days
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7. Empyema
(lung abscess/ empyema as
per NG) S. aureus, H. influenzae Grp A Strep, S. pneumoniae,
Oral anaerobes
Primary treatment is intercostal drainage with
concurrent antibiotics The intercostal drainage fluid should be sent for culture
sensitivity Piperacillin-Tazobactam 4.5gm IV 6hourly or Cefoperazone-Sulbactam 1.5 gm IV 8 hourly
+/- Clindamycin 600-900mg IV 8hourly
Duration of treatment: Minimum 6 weeks
Remarks: If no response in 72 hrs, then upgrade as per Culture and
sensitivity report
8.
Pneumocystis jiroveci Pneumonia
Cotrimoxazole DS (800+160) PO 2 TDS Duration: 14 days In patients with associated hypoxia parenteral
corticosteroids indicated
9. Anaerobic pneumonia
Piperacillin + tazobactam 4.5 gm IV QDS
+ Metronidazole 500 mg IV TDS Duration: 14 days
10. Bronchiectasis with
infective exacerbation H.
influenzae, P. aeruginosa
Co-amoxiclav 625 mg PO TDS
If no response then, Ceftriaxone 1 gm IV BD
+ Amikacin 500 mg IV OD
Duration: 7-10 days Remarks: Upgrade antibiotics as per culture and sensitivity report
11. Pulmonary tuberculosis MTB complex
As per RNTCP guidelines
12. Invasive Broncho
Pulmonary Aspergillus
pneumonia (Immuno- compromised patient)
Itraconazole 200 mg BD
Duration: 3 weeks
Alternatives: Voricanazole 6 mg/kg IV BD day 1 followed by 4mg /kg IV BD Duration : 2- 3 weeks
Voriconazole to be reserved for non responsive cases
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2. CNS Infections
Sr. No.
Conditions/ Expected
pathogens Revised MCGM recommendations
1. Acute Bacterial Meningitis S.pneumoniae N.meningitidis H.influenzae
Crystalline Penicillin – 20
lakh units / IV / 2 hourly or Ceftriaxone 2gm / IV / BD +/-
Vancomycin 1g (15 mg/kg) / IV / BD Duration: 10-14 days
+ Inj Decadron 8 mg stat followed by 4mg IV 8 hrly
Duration : 5 days
Remarks: Penicillins to be administered only after test dose. Indications for Vancomycin use: 1.diabetics with skin &
soft tissue infection 2. patients with acute osteomyelitis
3. neurosurgery/ shunt
2. Acute Bacterial Meningitis
(Elderly, alcoholics, immunocompromised)
Listeria mono-
cytogenes
Inj Ampicillin 2gm IV 4 hrly
Duration : 2 weeks
3. Brain Abscess S.Aureus, anaerobes, Streptococci, Gram neg.
bacilli, CoNS
Cefotaxime 2 gm IV 4-6 hrly Or Ceftriaxone 2g / IV / BD plus Metronidazole 500 mg IV / TDS
2nd line:
Meropenem 2gm IV TDS Duration- 2-4 weeks
Alternative/Remarks: Add Vancomycin if MRSA suspected
If fungal etiology confirmed, add Amphotericin B/
Voriconazole Consult neurosurgery for abscess aspiration/ excision
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4. Neurocysticercosis
Taenia solium
Albendazole 400 mg PO BD
+ Prednisone 1 mg/kg PO
OD Duration: 15 days
Remarks: Consider antiepileptic therapy for seizures
5. Spinal epidural abscess
S.aureus, Streptococcus spp.,
anaerobes, Gram negative
organisms
1st line:
Ceftriaxone 2gm /day IV BD +
Metronidazole 1500-2000 mg/day, IV 6 hrly intervals + Vancomycin 1 gm /day IV BD
2nd line:
Meropenem 2 gm IV 8 hrly
+/-
Vancomycin 1 gm /day IV BD Duration :3-4 weeks after surgical drainage
Remarks: Consider Meropenem to be added as per C/S report.
6. Subdural empyema
Oral anaerobes, H. influenzae
1st line:
Ceftriaxone 2gm /day IV BD + Metronidazole 1500-2000 mg/day, IV 6 hrly intervals + Vancomycin 1 gm /day IV BD
2nd line:
Meropenem 2 gm IV 8 hrly +/-
Vancomycin 1 gm /day IV BD
Duration :3-4 weeks after surgical drainage
Remarks:
Consider Meropenem to be added as per C/S report
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7 Cavernous or sagittal sinus
thrombosis, Intracranial
suppuration,
thrombophlebitis S.aureus, Grp A
Streptococci, H.influenzae
1st line:
Ceftriaxone 2gm IV BD + Metronidazole 500 mg IV 8 hrly
2nd line:
Meropenem 2gm IV 8 hrly + Vancomycin 1gm/day IV/BD Duration: for 6 weeks or until there is radiographic
evidence of resolution of thrombosis. Alternatives: 1st line: Cefotaxime 12 gm/ day IV 4 hrly
+
Metronidazole 500 mg IV 8 hrly
8. Meningitis-
Postneurosurgery or Penetrating head trauma
Meropenem 2gm IV 8 hourly
+ Vancomycin 15mg/kg IV 8 hourly For 14 days.
S. epidermidis, S. aureus,
Propionibacterium acnes, P.
aeruginosa, A.baumanii
Remarks: May need intra ventricular therapy in severe cases
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3.ENT infections
Sr. No.
Conditions/ Expected
pathogens Revised MCGM recommendations
1. Acute Sinusitis S. pneumoniae, H.influenzae M. catarrhalis
Co-amoxiclav 625 mg PO BD Duration:
10-14 days Alternative: Levofloxacin 500 mg PO OD Duration: 7 days Levofloxacin not indicated in children
2. Acute pharyngitis Majority viral
Suspect bacterial- Grp A Streptococcus
None indicated in viral
Bacterial: Co-amoxiclav625 mg PO BD
+/- Azithromycin 500 mg PO
OD Duration: 5- 7 days
Alternative: Cotrimoxazole (DS) 800/160 mg OD Or
Doxycycline 100 mg BD Or
Cefuroxime axetil500 mg BD
Or
Cefpodoxime
3. Acute epiglottitis H. influenzae, Anaerobes
Polymicrobial
Co-amoxiclav 625 mg PO BD Duration : 10 days
+ Metronidazole 500 mg PO TDS
Duration: 2-3 weeks
Alternative: Ceftriaxone 2g IV.
BD Duration: 7-10 days
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4. Oral Candidiasis
Candida spp
Gentian violet for LA
Till improvement For severe cases –
Fluconazole LA and 100-200 mg PO Duration:
2 weeks Remarks: Local Nystatin application for mild cases.
Correct factors predisposing to oral thrush. For prophylaxis, once weekly oral dose of fluconazole is
given.
5. Ludwig’s Angina, Vincent’s
angina Polymicrobial (Oral Anaerobes
Co-amoxiclav 1.2 gm IV BD Duration: 5–7 days + Metronidazole
500 mg PO TDS
Duration : 2-3 weeks (please check if duration for both is appropriate)
6. Acute Otitis Media S. pneumoniae, H.influenzae
M. catarrhalis
Co-amoxiclav 625 mg PO BD
Duration: uncomplicated - 5-7 days
severe complicated / <2 yrs for 10
days Remarks: Indications for antimicrobial therapy:
-High risk patients -Patients with complicated disease -Patients who do not improve after 48-72 hrs
-Newborns -Severely ill immunodeficiency
7. Prophylaxis for recurrent Otitis Media
Co-amoxiclav 625 mg PO BD/ 375mg PO TDS/ 1 gm PO BD depending upon age and body
weight Duration: 7 days Alternatives: Levofloxacin 500 to 750 mg/ day Or
Cefpodoxime 200 mg BD Or
Cefpodoxime with Clavulanic acid (200 /125) BD.
Avoid 3rd gen cephalosporins if possible, as they are
excellent ESBL inducers
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8. Chronic Otitis Media
S.aureus,Enterobacteriaceae. Pseudomonas Spp, anaerobes
Topical antibiotics during drainage
Ciprofloxacin 500 mg PO BD Or Ofloxacin 200 mg PO BD
Duration : 7 days
Alternative: Ceftazidime 30-50 mg/kg IV TDS (in
proven Pseudomonas infection) not to
exceed 6 g/day . In children, use Cefixime. Role of systemic antibiotics not proven.
In complicated cases, PiperacillinTazobactam 2.25/4.5 gm BD, or even TDS, or in some cases Meropenem if sensitive as per culture sensitivity report.
9. Otomycosis Candida spp
Fungal Otitis Externa Itraconazole 200mg BD daily
Duration: 2 weeks Clotrimazole ear drops + Topical 2% salicylic acid
Suction evacuation
Remarks: Recommended to do culture
10. Otitis externa S. aureus
Co-amoxiclav 625 mg PO BD/ 375mg PO TDS/
1 gm PO BD depending upon age and body weight And
Topical Ciprofloxacin ear drops Duration:
7 days Alternative/Remarks:
Doxycycline 100 mg PO BD Or
Ciprofloxacin 500 mg PO BD Cleansing external ear canal.
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11. Invasive/ Necrotising Otitis
Externa Pseudomonas spp
Ceftazidime 1 g TDS
Or Ciprofloxacin 500 mg PO BD or 200 mg IV BD
Early cases – oral & topical quinolones Duration to be adjusted based on severity and
underlying condition such as Diabetes mellitus Diabetic
– Piperacillin IV for 10-14 days Alternative: Piperacillin-Tazobactam 4.5 g IV TDS
+ Aminoglycosides 500mg IV OD + Local Ciprofloxacin drops
Duration:7 days If severe, Quinolone + Beta lactam beta lactamase inhibitor
Duration: 6 weeks If diagnosed fungal aetiology, Fluconazole (Candida spp)
and Itraconazole (Aspergillus spp)
12. Diphtheria
C. diphtheria
Erythromycin
40 mg/kg /day IV (max) OR 2gm/day + Penicillin G IV
300000 IU/day (<10kg wt)/ 600000 IU/day (>10kg wt)
+ Anti-diphtheria serum
Duration: 14 days or Until patient is able to swallow
Remarks: Penicillin should be administered only after test
dose. Anti-diphtheria serum For children: Laryngeal: 20-40,000 U
Nasopharyngeal: 40-60,000
U Extensive disease:
60-80,000 U
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13. Laryngitis
Viral (mainly), Rarely Bacterial- Streptococcus, Moraxella
Co-amoxiclav
625 mg PO TDS Duration:7
days Remarks: Antibiotics are not recommended unless Grp A Strep is
isolated.
14. Laryngotracheobronchitis
Co-amoxiclav 625 mg PO
TDS Duration:7 days
Remarks: Levofloxacin 400 mg PO BD
15. Pre op prophylaxis – Major head and neck surgery including implant surgeries
Inj Cefazolin 2 gms
(IV) 1st dose at induction
or
Inj Cefuroxime sodium 1.5 gm (IV)
2nd dose within 24 hrs
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4.Ophthalmic infections
Sr. No.
Conditions/ Expected
pathogens Revised MCGM recommendations
1. Blepharitis (Anterior and
posterior ) S. aureus, S. epidermidis, Non infective causes
Anterior :
Chloramphenicol e/d
or e/o (1%w/w) ;
Duration - 4 to 6
weeks Posterior
blepharitis: above + Doxycycline 100mg PO BD
(Not given to pregnant women)
Duration: 1 week. Or
Azithromycin 500 mg PO OD Duration : 3 days In addition - 1. Warm wet compress to the lid with 1:4 baby shampoo
or with warm 3 % bicarbonate of soda lotion. 2.Eyelid hygiene.
3. Artificial tears if associated with dry eye. Alternative: - Topical sodium fusidic acid (1%)
2. Hordeolum (Stye) S. aureus
Amoxicillin 500 mg PO QDS Duration: 5 days +
Oral NSAIDs
In addition 1.Warm compresses 2. Some cases require incision and drainage of the stye. Alternatives Ampiclox (250 mg each)PO TDS
Duration: 5 days If associated conjunctivitis- Gatiflox 0.3%/ Moxifloxacin 0.5% e/d QDS
Duration: 1week
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3. Purulent Conjunctivitis
Viral – Adenovirus
(Antibiotics prescribed to prevent secondary bacterial
infection) Povidone Iodine e/d 5% solution QDS +
Steroid (if pupillary area is involved) e/d Fluorometholone 0.1% 1 drop 4 times a day in
tapering fashion +
Topical Moxifloxacin 0.5% 1 hrly +
Oral NSAID Duration: Approximate 1 week In addition
1.Lid hygiene 2.Protective glasses 3. Artificial tears
4. Purulent Conjunctivitis
Bacterial –Chlamydia, S.
aureus, N. gonorrhoeae, S. pneumoniae
Povidone Iodine e/d 5% solution QDS +
Topical Moxifloxacin 0.5% 1 hrly
Duration: Approximate 1 week. In
addition, Remarks: 1.Lid hygiene 2.Protective glasses 3. Artificial tears if associated with dry
eye. Alternatives Bacterial: Gatifloxacin 0.3% Or Levofloxacin 0.5%,
Dose: 1-2 drops every 2hrs while awake during the first 2
days, then every 4-8hrs Duration: 7 days
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5. Inclusion Conjunctivitis
(Trachoma) Chlamydia trachomatis
Topical Antibiotic e/o
erythromycin 0.5% TDS
e/o tetracycline 1%TDS + Tab Azithromycin 1000 mg POOD; repeat after 1
week Duration: 3-4 weeks Alternative: Erythromycin
250 mg PO BD or Ofloxacin 400
mg PO OD or Doxycycline 100
mg PO BD or
Tetracycline250 mg PO QDS (avoid in pregnant women
and in children) Duration: 3-4 weeks
6. Orbital Cellulitis
S.pneumoniae, H.influenza, M.catarrhalis
S.aureus, anaerobes, Grp A
Streptococci, Gram Negative bacilli, Post Trauma
Start organism specific treatment after culture and
sensitivity report. Consider fungal culture Vancomycin 1gm iv BD +
Levofloxacin 750 mg IV once daily +
Metronidazole 500mg IV TDS infusion
Duration – 7 to 14 days
Remarks: Cloxacillin 2 gm IV 4 hrly +
Ceftriaxone 2gm IV 24 hrly +
Metronidazole 500mg IV TDS infusion Duration – 7 to 14 days
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7. Corneal Ulcer/ Keratitis
HSV
Viral-
Topical Acyclovir 0.3% e/o 5 times a day +
Acyclovir 400 mg PO 5 times if accompanied by iritis Or Ganciclovir 0.15% ophthalmic gel 5 times a day until
corneal ulcer heals, followed by one drop three times daily
for 7 days Duration :3 weeks Acyclovir 400 mg PO BD in recurrent herpetic eye
disease Trifluridine ophthalmic soln 1drop 2 hourly, up to 9times/day until reepithilealised, then
1 drop 4 hourly upto 5 times/day
Total duration: 21 days Corneal scraping and Culture should be done whenever possible. Artificial eye drops to be used in case of dry eye
Oral NSAID and e/d Homatropine may be added in
selected cases.
8. Corneal Ulcer/ Keratitis
Varicella zoster
Viral-
Topical Acyclovir 0.3% e/o 5 times a day
+ Acyclovir 800 mg PO 5 times a day if accompanied by
iritis Duration :3 weeks Acyclovir 400 mg PO BD in recurrent herpetic eye
disease Alternative/Remarks: Famciclovir 500mg BD/TID Or
Valacyclovir 1gm oral TID Duration:
10 days. Corneal scraping and Culture should be done whenever possible.
Oral NSAID and e/d Homatropine (2% TDS) may be
added in selected cases for 2 weeks
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9. Corneal Ulcer/ Keratitis
Bacterial - S.aureus, H.influenza, S.pyogenes
Bacterial-
Amikacin 3% / Moxifloxacin 0.5% 1 drop hourly e/d
which is tapered according to response Or Tobramycin e/d 1.3% (fortified) 1 drop hourly
And e/d Homatropine 2%
TDS Duration: 7-14 days Gatifloxacin 0.3% ophthalmic Solution 1 drop 1 hourly
for 1st 48hrs then reduce In cases of virulent corneal ulcer:
Fortified Cefazolin 5% e/d one drop every half hour
+ Fortified Tobramycin 1.3% e/d 1 drop hrly for the first
48 hrs and then reduce as per symptoms Duration: 2 weeks
10. Corneal Ulcer/ Keratitis
Fungal
Fungal-
1. For filamentous fungi: Natamycin 5% e/d half
hourly for the first two days after which it is
reduced to one drop every hour 2. For yeasts:
Amphotericin B 0.15% e/d Homatropine e/d 2 % TDS to be added in both
cases Duration: 4 weeks Remarks: Voriconazole e/d 1% 1 drop hrly and gradually tapered
over 8 weeks Duration: 8 weeks (Tapered as infection resolves)
If liver function tests are within normal limits then add,
Oral Ketoconazole 200 mg BD – dose to be titrated as per response as well as liver function tests
Duration: 3-4 weeks Use artificial tears in case of dry eye
11. Eye infection in Contact Lens Users
Acanthamoeba spp
PHMB (0.02%) hourly +
Chlorhexidine (0.02%) hourly + Homatropine e/d 2% TDS
Duration: 2 days, then tapered. Total duration
of treatment is 3 weeks Remarks: Culture is mandatory. Consider Propamidine isethionate (0.1%) as an alternative.
In late cases, TPK may be needed.
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12. Eye infection in Contact
Lens Users Pseudomonas spp
Pseudomonas keratitis
(topical and systemic antibiotics) Tobramycin fortified e/d 1.3 % 1 drop 1 hourly Or
Gentamicin 14 mg/ml 1 drop 1 hourly
Duration: 15 days
Alternative/Remarks: Culture is mandatory. If no response then Colistin e/d 0.19% 2 hrly Duration: 2 weeks
Consider Propamidine isothionate (0.1%) as an
alternative. In late cases, TPK may be needed.
13. Dacrocystitis H. influenza, S. aureus, S.
pyogenes, P. aeruginosa
Gatifloxacin 0.3% Or Moxifloxacin 0.5% e/o 6 times a
day +
Systemic Co-amoxiclav 625 mg PO TDS Duration : 7 days In addition,
• Hot fomentation and massage
• Oral NSAID’s for 1 week
• DCR/DCT to be done after inflammation subsides
in acute cases and can be done as a primary
indication in chronic cases
14. Endophthalmitis
S. epidermidis S. aureus,
Streptococcus spp, Enterococcus Spp, Gram
negative bacilli, anaerobes
Intravitreal antibiotics:
Vancomycin 1 mg in 0.1 ml +
Ceftazidime / Cefazolin 2.25 mg in 0.1 ml or Amikacin 400 mcg in 0.1 ml or Gentamicin 200 mcg in 0.1 ml
Systemic antibiotics Vancomycin 1gm IV BD and Amikacin240 mg IV TDS
or Vancomycin and Ceftazidime 2gm IV TDS Topical antibiotics Fortified tobramycin 1.3% or fortified cefazolin 5% 1
drop 1 hrly to be reduced according to response Duration: 2 weeks Important considerations
• Homatropine e/d to be added
• Intravitreal antibiotics to be repeated after 48 hrs in
case of no response
• Pars plana vitrectomy or vitreous aspiration may be
performed.
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• Send specimen for culture – bacterial and fungal. • Treatment is tailor made for the cause whether
exogenous(post-op,/posttrauma) or endogenous If
fungal, add AmphotericinB
15 Endophthalmitis
Candida sp, Aspergillus sp.
Intravitreal antifungals:
Amphotericin B 5 mcg in 0.1 ml
or Voriconazole 0.1 ml/100 mcg
• Pars plana vitrectomy or vitreous aspiration may
be performed.
• Send specimen for culture – bacterial and fungal. • Treatment is tailor made for the cause , whether
exogenous(post-op,/posttrauma) or endogenous • If fungal, add AmphotericinB
16 Retinitis
HSV Varicella Zoster Virus
IV antiviral drugs:
Acyclovir IV 10 mg/kg 8 hrly for 10-14 days and then
orally 800 mg five times a day for 6-12 weeks
Alternative/ Remarks: Resistant cases require intra vitreal anti-viral agents.
17 Iridocyclitis
To be deleted from MCGM guidelines
18 Uveitis
Infectious, Traumatic, Immune mediated, Viral-
Herpes simplex
To be deleted from MCGM guidelines
19 Pre-operative Prophylaxis Clean cases
Cataract, terygium,
glaucoma, strabismus,
lid(entropion,
exotropion,ptosis), corneal
transplant
Moxifloxacin 0.5% e/d 3 times previous day of
surgery.
Instill Povidone Iodine 5% eye drops in conjunctiva (to
remain for 3 minutes), immediate preoperative
preparation
In addition,
1. Trimming of eye lashes just before surgery 2. Eye wash with 5% betadine prior to surgery
3. Head bath and face wash prior to surgery 4. Check patency of nasolacrimal duct before
surgery
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20 Contaminated cases
Endopthalmitis, corneal
ulcer, post traumatic tear
with infection,intraocular
foreign body, lacrimal sac surgery, dacrocystitis
Systemic Cefotaxime 1 gm IV TDS Or Ceftriaxone 1.5
gm IV BD one day prior to surgery and continue 7 days
post surgery + Topical Moxifloxacin 0.5% 4-6 times a day
+ Intracameral Moxifloxacin intra op at the end of surgery
Systemic Cefotaxime 1 gm IV TDS Or Ceftriaxone 1.5 gm
IV BD one day prior to surgery and continue 7 days post
surgery
+
Topical Moxifloxacin 0.5% 4-6 times a day
+
Intracameral Moxifloxacin intra op at the end of surgery In addition,
1. Trimming of eye lashes just before surgery
2. Eye wash with 5% betadine prior to surgery 3. Head bath and face wash prior to surgery
4. Check patency of nasolacrimal duct before
surgery
21 Corneal foreign body Patch for 24 hrs for epithelisation before increased
cycloplegia Antibiotic Chloramphenicol applicap Next day: Antibiotic drops Moxifloxacin/ Gatifloxacin
X 3 days Homatropine 2% BD for 1-2 days
In addition, 1. Trimming of eye lashes just before surgery
2. Eye wash with 5% betadine prior to surgery 3. Head bath and face wash prior to surgery 4. Check patency of nasolacrimal duct before
surgery
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5.Bone And Joint Infections
Sr. No.
Conditions/ Expected
pathogens Revised MCGM recommendations
1 Acute osteomyelitis / Septic arthritis S.aureus, Streptococcus pyogenes
Enterobacteriaceae
Amoxicillin + clavulinic acid 1.2 g IV BD Or Cloxacillin 1gm IV QDS Or
Linezolid 600mg IV BD in proven MRSA Duration IV for 2-3 weeks followed by oral for a minimum of 6-8
weeks (maximum duration upto 3 months)
2 Chronic osteomyelitis S.aureus,
Enterobacteriaceae, Pseudomonas
Primary treatment Surgical debridement and then send sample for
culture and sensitivity (bacterial, fungal,
mycobacteria). If culture positive then treat as per
culture sensitivity report, until then start Cloxacillin 1gm IV QDS
Or Cefuroxime 1.5gm IV 12 hrly
+ Amikacin 500-750mg IV OD
If culture negative then Cloxacillin 1gm IV QDS
Or Cefuroxime 1.5gm IV 12 hrly + Amikacin 500-750mg IV OD
Duration Minimum 3 wks IV and continued as per patients response
then shift to oral. Minimum duration of treatment – 6-8 wks and extended as per clinical response for maximum 3 months
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3 Open Injuries - Gram
Negative & S. aureus
Cephazolin 2gm IV 12 hrly
Or Ceftriaxone 2 gm IV OD Or Cefuroxime 1.5gm IV 12 hrly
+ Amikacin 500 -750 mg IV OD + Metronidazole 500 mg IV 8 hrly To be given pre-op and upto 72 hrs post-op
4 Prosthetic Joint Infections - Grp A,B,G &
viridans Strep S. aureusCoNS
Enterococcus Gram Negative Bacilli
If clinical evidence of infection Debride and send for culture and start Ceftriaxone 2g IV OD +
Linezolid 600 mg IV BD
Or Vancomycin 1gm IV BD When culture reports available change as per culture
sensitivity report. If culture negative continue the above treatment. Duration
Minimum 6 wks and upto maximum of 3 months.
5 Bursitis
S. aureus
No antibiotics
If culture positive, Cloxacillin 500mg POQDS or Co-amoxiclav 625mg PO TDS
Duration : 5 days
Alternatives: If septic bursitis then Flucloxacillin 500mg , erythromycin, clarithromycin
BD/ QID for 7 days
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6 Gas Gangrene- Clostridia
Surgical debridement is primary therapy
Hyperbaric oxygen debated Antibiotics Penicillin + Clindamycin
Or In Penicillin allergic patients, Clindamycin + Metronidazole Dose: Clindamycin 600 - 1200 mg IV/day in divided
doses Penicillin G 24 million units/day divide 4-6hrly IV
Metronidazole 500 mg IV TDS
Duration : 2-4 weeks depending on patient’s response
Alternatives: Penicillin to be administered only after test dose. A
combination of penicillin and metronidazole may be
antagonistic and is not recommended. Ceftriaxone 2g IV BD Or
Erythromycin 1 g QDS IV (not by bolus)
Pre operative prophylaxis (revised MCGM guidelines)
1. Clean soft tissue surgery
without implant. Single dose Cephazolin 2gm IV Or
Single dose Co-amoxyclav 1.2gm IV
Eg ; excision of benign
soft tissue tumour.
Or Single dose Cefuroxime 1.5gm IV 60
mins prior to incision.
2 Closed trauma requiring
open reduction and
Fixation with implant
Cephazolin 2gm IV Or
Co-amoxyclav 1.2gm IV Or Cefuroxime 1.5gm IV
Given pre-op and IV 12hrly for 2 doses.
3 Open trauma requiring
debridement and Internal
or external fixation.
Cephazolin 2gm IV 12 hrly
Or
Ceftriaxone 2 gm IV OD Or Cefuroxime 1.5gm IV 12 hrly + Amikacin 500 -750 mg IV OD
+ Metronidazole 500 mg IV 8 hrly To be given pre-op and upto 72 hrs post-op
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4 Primary joint replacement
Cephazolin 2gm IV 12 hryly
Or Co-amoxyclav 1.2gm IV 12 hryly or Cefuroxime 1.5gm IV 12 hrly
+ Amikacin 500 -750 mg IV OD Pre-op and between 2-5 days post op
5 Major spinal surgery lasting more than 8 hrs
Cephazolin 2gm IV 12 hryly Or Co-amoxyclav 1.2gm IV 12 hryly
Or Cefuroxime 1.5gm IV 12 hrly + Amikacin 500 -750 mg IV OD Pre-op till 5 days post op
6 Minor spinal surgery
Cephazolin 2gm IV 12 hryly Or Co-amoxyclav 1.2gm IV 12 hryly
Or Cefuroxime 1.5gm IV 12 hrly
+ Amikacin 500 -750 mg IV OD Pre-op and upto 48 hrs post-op
7. Revision joint surgery Screen all patients for MRSA
(for aseptic loosening)
If not MRSA carrier then start Cephazolin 2gm IV 12 hryly
Or Co-amoxyclav 1.2gm IV 12 hryly
or Cefuroxime 1.5gm IV 12 hrly +
Amikacin 500mg – 750 mg IV OD
To be continued for 5 days post op. If MRSA carrier to the above add
Vancomycin 1gm IV 12 hrly And treat for MRSA carriage
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6.Skin and soft tissue infections
Sr.
No .
Condition/ Expected
pathogens
Current MCGM Guidelines
1 Acne vulgaris
Propionibacterium
acnes
Clindamycin (1%) gel/lotion to be applied locally BD
Duration - 15days +/- (depending on severity) Cap. Doxycycline 100mg PO OD; Duration - 15 days Or
Oral Azithromycin 500 mg OD for 3days. Repeat after one week (for upto 6 weeks)
To follow up after 15 days for clinical evaluation and to assess
response to treatment
Alternatives:
Ointment Erythromycin base (1.5%) to be applied locally BD;
Duration - 15days +/- (depending on severity) Minocycline 100 mg PO OD
Duration - 20 days
Antibiotic sparing agents have proved effective. To be given
in addition to oral treatment: Topical benzoyl peroxide 2.5% gel or Tretinoin 0.025% cream
Systemic- Oral contraceptives with anti androgenic progesterone
Dapsone Anti-androgenic agents
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2 Furunculosis
S. aureus –
Methicillin
susceptible S.
aureus –
Methicillin
susceptible
Co-amoxiclav 625 mg PO TDS
Or Cefadroxil 250 / 500 mg PO BD Duration : 7-10 days Chronic cases -
Minocycline or Doxycycline 100 mg PO BD In severe cases - Clindamycin300–450 mg/kgTDS
Alternatives: TMP-SMX 800/160 PO BD or Cloxacillin 250- 500 mg QDS Duration: 7days Local –
Sodium fusidate 2% twice
daily for 3-4 wks
Or
Mupirocin 1% twice daily
Or Povidone iodine ointment
3 Carbuncle S. aureus, Gram
negative rods
1. Incision drainage 2. Co-amoxiclav 625 mg PO TDS
Or
Cefadroxil 500 mg PO BD
Duration :7 days
Alternatives: T. Cephalexin
500 mg PO QDS
Duration : 7 days
4 Cellulitis S. pyogenes, Other
streptococci, S.aureus
Co-amoxiclav 625 mg PO TDS Or TMP/SMX 800/160 mg PO BD
Duration : 7-10 days
Alternatives: Cefazolin, 1–2 g TDS
or Ampicillin/sulbactam, 1.5–3 g IV
QDS or Clindamycin, 600–900 mg IV TDS
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5 Erythrasma
Azithromycin 500 mg PO OD
Duration : 3 days Or Erythromycin 500 mg PO QDS
Duration: 5 days + Topical erythromycin / Clotrimazole 1%/ Miconazole 2%/ Clindamycin / Fusidic acid
Duration : 2 weeks
6 Erysipelas S.
pyogenes, other streptococci,
S.aureus,
(FacialS.pneumoniae
also) In diabetics –
maybe associated with
Entero-
bacteriaeceae
Co-amoxiclav 625 mg PO TDS Duration : 7-10 days Or Erythromycin 500 mg QDS
Duration : 7-10 days
Alternatives: Cefazolin, 1–2 g
TDS or Ampicillin/sulbactam, 1.5–3 g IV
QDS or
Clindamycin 600–900 mg IV TDS
7 Folliculitis
S.aureus P.aeruginosa (Hot tub)
Co-amoxiclav 625 mg PO TDS
Duration : 7days Or Ciprofloxacin 500 mg PO BD
+ / - Local: 1% Mupirocin/ Sodium fusidate / Povidone
iodine/ neomycin containing ointment
8. Chronic Folliculitis
S.aureus P.aeruginosa (Hot tub)
Doxycycline 100 mg PO OD
Duration: 2-4 weeks or Dapsone 100 mg PO OD
Duration: 2-4 weeks Topical: 1% Mupirocin/ Sodium fusidate / Povidone iodine/ neomycin containing ointment
Alternatives: TMP/SMX 800/160 mg PO BD Duration: 2-4 weeks
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9 Hiradenitis
suppurativa S.aureus, S.pyogenes, Anaerobes, Pseudomonas spp.,
Entero-
bacteriaceae
Co-amoxiclav 625 PO TDS
Duration:7days Or Azithromycin 500 mg PO OD
Duration: 3days
Alternatives: Minocycline 100 mg BD or Doxycycline 100 mg BD or Clindamycin 300 mg QDS
Or TMP/SMX 800/160 mg PO BD Antibiotic sparing agents are recommended (Retinoids and
antiandrogens)
10 Ecthyema Grp A Strep, S. Aureus
Co-amoxiclav 625 mg PO TDS Or Cefadroxil 250 / 500 mg PO BD Duration : 7-10 days Topical
mupirocin ointment/ Sodium fusidate 2% is also effective. Alternatives:
For minor lesion, those on dangerous area of face and in
children Azithromycin 500 mg PO OD
Duration: 3days Or
TMP/SMX 800/160 mg PO BD Duration: 7-10 days
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11 Madura foot,
Actinomycoticmycetoma/
Eumycetoma Nocardia spp. Actinomadura spp./
Fungal causes
Actinomycotic mycetoma:
Inj Amikacin 500 mg IM BD + Inj Ampicillin 500 mg IV QDS
Duration of injectable antibiotics: 2 weeks (to be
repeated at 2 week intervals for a total duration of three
months) + TMP/SMX 800/160 mg PO BD Duration: 3 months Itraconazole 100 -200 mg BD
Duration: 3 months
Alternatives: Inj. Crystalline Penicillin 50,000units/kg body weight IV
in 4 divided doses/ day Duration: 2 weeks Surgical debulking done to reduce infection load
Eumycetoma: Itraconazole 100 -200 mg BD
Duration: 3 months
12 Muco-cutaneous
candidiasis Candida
albicans
Correct the underlying predisposing condition Cutaneous Candidiasis
Clotrimazole cream (1%) to be applied locally twice daily
Or
Miconazole 2% cream
Duration: 2 weeks.
To follow up after 2 weeks to assess response to therapy. Alternatives:
Cap.Fluconazole (100 mg) 2 capsules on day 1 followed by
1 capsule once daily for 2 weeks Or Nystatin Suspension 100000 Units to swish around in the
mouth and then swallow four times daily
13 Paronychia
(Acute/chronic) Acute:
Staphylococcal infection
Chronic : Candida
Acute:
Co-amoxiclav 625 PO BD and Incision and drainage to relieve pain
Chronic:
Oral fluconazole 150 gm /wk
Topical miconazole / clotrimazole. Alternatives: Ciclopirox suspension applied to affected area(s) BID/TDS
Or
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Econazole cream applied to affected area(s) BD/TID
14 Localised Pyoderma
Topical Treatment: Sodium fusidate 2% Or Mupirocin 1%
Or Povidone iodine ointment
Duration: 7-10 days Alternatives: Topical Nadifloxacin cream Duration: 7-10 days
15 Puncture wounds
(foot) S.aureus, Strep spp,
P.aeruginosa, other GNR
To be deleted from MCGM guidelines
16 Seborrhoiec
dermatitis
Malassezia spp
To be deleted from MCGM guidelines
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17 Other fungal
infections of skin, hair and nails
Tinea versicolor, Dermatophytes
a) Tinea corporis/Tinea cruris
Systemic therapy Terbinafine 250 mg OD/BD Duration: 14 days
Or Itraconazole 100 -200 mg BD Duration: 14 days To follow up after 2 weeks to check response to therapy
Topical therapy
Whitfield ointment + Cream Clotrimazole (1%) to be applied locally twice daily for
2 weeks Or Amorolfine cream 1% Or Luliconazole Cream
Alternative treatment (T. corporis/T cruris)
Griseofulvin 250 mg PO BD Duration: 6 weeks to 6 months
b) Tinea capitis/Tinea barbae/Tinea pedis/Tinea manuum
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Systemic therapy
Terbinafine 250 mg OD/BD Duration: 21 days Or
Itraconazole 100 -200 mg BD Duration: 21 days To follow up after 2 weeks to check response to therapy.
Topical therapy Whitfield ointment
+ Cream Clotrimazole (1%) to be applied locally twice daily for 2 weeks Or
Amorolfine cream 1% Or Luliconazole Cream
c) Other fungal infections of skin, hair and nails (Pityriasis/Tinea Versicolor of trunk/face)
Systemic therapy Fluconazole 200 mg 2 tablets once a month
Duration: 3 months
Topical therapy Lotion Clotrimazole (1%)/ miconazole/ oxyconazole/
selenium sulfide applied locally twice daily for 6 weeks To
follow up after 3 weeks to check response to therapy
18 Scabies Sarcoptes scabiei
Permethrin 5% cream OR GBH 1 % lotion (gamma benzene hexachloride) Apply Permethrin entire skin chin down to and including toes.
Leave on for 8-14 hours Repeat application after 10 days
Alternatives: Single Dose Ivermectin 200 µg/kg PO Take 2nd dose of Ivermectin after 10 days
19 Onychomycosis
Fungal
Itraconazole 100-200 mg BD
Duration: 6-12 weeks Or Terbinafine 250-500 PO per day Duration: 6-12 weeks After 3 months, repeat testing
Alternative: Griseofulvin 250-500 mg PO BD Duration: 6-12 months
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7.CVS Infections
Sr. Condition/ Expected No. pathogens Current MCGM Guidelines
1. Infective endocarditis (native valve)
S. viridians, Enterococcus, MSSA,
MRSA, Culture
negative
I. Inj Ceftriaxone 2 gm IV / IM single dose Duration : 4 weeks
+ Inj Gentamicin 3 mg/kg/day IV or IM OD Duration : 2
weeks II. Inj Ampicillin 12gm/day(divided in 4-6 doses )
+ Inj Cloxacillin 12gm/day (divided in 4-6 doses )
Duration :4 weeks + Inj Gentamycin 3 mg/kg/day OD dose.
Duration: 2 weeks -For patients unable to tolerate beta lactams or beta
lactam resistance Vancomycin 30 mg/kg/day IV in 2 doses
+ Gentamicin (3 mg/kg/day IV. or i.m.) Note
: OD dosing of Gentamicin decreases the
nephrotoxicity
2 Infective endocarditis
(prosthetic valve) MSSA, MRSA
Early (<12 months )
Inj Vancomycin 15-20 mg / kg /day IV in 2 doses
Duration : 6 weeks + Gentamicin (3 mg/kg/day IV or
IM in OD dose ) Duration : 2 weeks + Rifampicin 900-1200 mg PO in 2-3 divided doses Duration- 6 weeks Late (>12 months )
Similar to Empirical Therapy for native valve Endocarditis with total duration of 6 weeks
Remarks:
• Inj Gentamicin is usually used for two weeks. The
duration of treatment is 4-6 weeks of effective
antibiotics.
• Rifampicin should not be used in the first 5 days
till bacteremia is cleared because of antagonistic
action of antibiotics against plaktonik /replicating
bacteria
3. Pacemaker/ Defibrillator infection Local microbial spectrum
Local antibiogram
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CARDIOVASCULAR SYSTEM INFECTIONS POST SURGERY IN ADULTS
Sr. No
Condition/ Expected
Pathogens Revised MCGM recommendations
1 CABG
Same as before
2. Pacemaker/ Defibrillator Implantation S. aureus S. epidermidis
Gram Negative Bacilli
Amoxycillin-clavulanic acid 1.2 g IV. 60 min prior to
skin incision and 12 hours after the procedure f/b 1g
PO BD for 3 days
3. Cardiac Catheterization
Amoxycillin-clavulanic acid 1.2 g IV. 60 min prior to
skin incision and 12 hours after the procedure f/b 1g
PO BD for 3 days
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8.Intra-abdominal infections
Sr. No
Conditions/ Expected
Pathogens Revised MCGM guidelines
1. Abscess-Liver Pyemic Enterobacteriaeceae, Enterococcus,B.fragilis Other anaerobes
Ampicillin + Sulbactam 1.5g IV TDS Or Ceftriaxone 1.0 g IV BD
Or Ciprofloxacin 500 mg BD IV Plus
Metronidazole 500 mg IV TDS or 800 mg oral
TDS Duration : 2 weeks Alternatives: Piperacillin + tazobactam 4.5 gm IV QDS X 2 weeks
Remarks: Ultrasound guided drainage indicated in large
abscesses, signs of imminent rupture and no response to
medical treatment.
2. Abscess-Liver Amoebic E.histolytica
Metronidazole 800 mg PO TDS / 500 mg IV TDS +
Tab Chloroquine 250 mg BD +
Cefotaxime 1 gm IV 8 hrly
Duration : 10-14 days
Alternative: Diloxanide furoate with metronidazole 500 mg + 400 mg
TDS X 10 days ( for cyst passers)
3. Acute gastroenteritis (indoor patient) Suspected- viral
Bacterial –
Pathogenic E.coli
None indicated in viral
Bacterial: Ciprofloxacin 500 mg IV BD Or Ofloxacin 200 mg IV BD Duration – 3-5 days
(convert to oral when patient stabilizes)
Alternative: Doxycycline100 mg PO BD Duration: 3-5 days OR Co-trimoxazole 800/160 mg PO OD ;
Duration: 3-5 days
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3a Acute gastroenteritis
(OPD patient)
Suspected- viral Bacterial – V cholera
None indicated in viral
Bacterial: Doxycycline- 100 mg PO BD
Or Ciprofloxacin 500 mg BD
Duration - 3-5 days
Remarks:
Rehydration is life saving
4a Dysentery - Bacillary Shigella spp Campylobacter jejuni
Pathogenic E.coli
Ciprofloxacin 500 mg BD Or Ofloxacin 200 mg BD
(for mild cases given orally and IV for indoor
patients/ patients with severe illness) Duration - 5
days Alternatives: Ceftriaxone 2gm IV OD for 5 days Remarks: For Campylobacter the drug of choice is
Azithromycin
4b Dysentery - Amoebic
(OPD patient) E.histolytica
Metronidazole 400 mg PO TDS
Duration- 7 days For severe
cases: Metronidazole 500 mg IV 8 hrly for 7-10 days Alternatives: Tinidazole 2gm oral stat Add Diloxanide furoate 500 mg TDS for 10 days for cyst
passers
5 Dysentery – Unknown OPD patient
Ciprofloxacin 500 mg PO BD +
Metronidazole 400 mg PO TDS Duration - 5 days If no response to Ciprofloxacin, add Metronidazole 400 mg
PO TDS Alternatives:
Ofloxacin 200 mg PO BD
Duration: 5 days + Tinidazole 2gm oral stat
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6 Cholangitis
Enterobacteriaeceae, Anaerobes
Piperacillin- tazobactam
4.5 gm IV TDS + Metronidazole 500 mg IV TDS
Duration – 7 days
Alternatives: If no response after 72 hrs add, Gentamicin 1 mg/kg IV TDS Or
Amikacin 15 mg/kg IV OD Duration- 7 days Upgrade to higher antibiotics as per culture and sensitivity
report
Meropenem to be reserved for post surgical/ endoscopic cases
Remarks: Surgical or endoscopic intervention to be
considered if there is biliary obstruction. High prevalence of ESBL producing E.coli, Klebsiella
sp.strains. De- escalate therapy once antibiotic susceptibility
is known.
7 Cryptosporidiosis
Cryptosporidium parvum
Nitazoxanide500 mg (PO) BD Duration- 3 days
8 Diarrhoea – C.difficile
Metronidazole 400 mg PO TDS
Duration - 10-14 days
In seriously ill add, Vancomycin -125 mg (children) / 500 mg (adults) , PO
QDS Duration- 10-14 days Remarks: Discontinue the causative antibiotic.
Correct fluid and electrolyte loss. Intravenous vancomycin is not recommended since
bactericidal concentrations are not achieved in the colon.
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9 Enteric fever
Salmonella typhi / Salmonella paratyphi A/B/C
Ceftriaxone 2 gm IV BD
+ Azithromycin 1 gm (PO or IV ) OD
*Duration: 7 days If patient discharged earlier, switch to Oral Cefixime 200 mg BD + Azithromycin 500 mg BD
*Duration: 7 days For susceptible strains with no response to Ceftriaxone
give, Chloramphenicol 500 mg IV QDS ; Duration: 14 days
*Total duration of therapy if IV drugs are given is 7 days. If
IV drugs are given for 7 days in toto then no oral drugs are
required However, if patient is discharged earlier than 7 days then
duration of treatment for IV plus oral is 10 – 14 days.
10 Acute cholecystitis Enterobacteriaeceae,
Enterococci, Anaerobes
All IV Ceftriaxone 1 gm BD
Or Piperacillin- Tazobactam 4.5 gm TDS
+
Metronidazole 500 mg TDS
Duration- 7-10 days
Alternatives/remarks:
Patients unresponsive to antibiotics may require surgery.
11 Spontaneous Bacterial
Peritonitis Enterobacteria-eceae
Enterococci
S.pneumoniae naerobes
All IV
Cefotaxime , 2 gm , TDS Or
Piperacillin- Tazobactam 4.5 gm TDS +
Metronidazole 500 mg TDS
Duration - 7 days Alternatives: Ceftriaxone 1 gm BD Duration - 7 day
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12. Perforative peritonitis
Enterobacteriaeceae Enterococci P.aeruginosa,
Anaerobes
All IV
Piperacillin- tazobactam 4.5 gm TDS +
Metronidazole 1 gm TDS
Duration - 7-10 days Alternative: Imipenem 1 gm TDS Or Meropenem 1 gm TDS + Metronidazole 1 gm TDS If no response then upgrade as per culture and sensitivity
report Addition of cover for yeast: Fluconazole 800 mg IV loading
dose day 1, followed by 400 mg 2nd day onwards Duration: ? Remarks: Source control is important to reduce bacterial load.
If excellent source control – for 5-7 days; other wise 2- 3
weeks suggested.
13 Intra abdominal
abscess Enterobacteriaeceae
Gram pos cocci Anaerobes MTB Complex (rare)
Mild – Moderate: Ceftriaxone 1 gm IV BD
+ Metronidazole 500 mg IV TDS Severe: Piperacillin- Tazobactam
4.5 gm IV TDS
or
Imipenem 1 gm + Cilastatin IV +
Metronidazole 500 mg IV TDS Duration
- 10 days or longer
Alternatives/Remarks: Antibiotics should be administered early.
Drainage should be considered.
If no response then modify as per culture sensitivity report.
Addition of cover for yeast: Fluconazole 800 mg IV loading
dose day 1, followed by 400 mg 2nd day onwards
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14 Gastric Ulcer Disease /
Peptic Ulcer Disease H.pylori
PPI Pantoprazole 40 mg PO BD
+ Clarithromycin 500 mg PO BD +
Amoxicillin 1 gm PO BD
Duration 2 weeks
Alternative: PPI 40 mg + Clarithromycin 500 mg
+ Metronidazole 500 mg
15 Liver - Hydatid Disease E. granulosus
Albendazole 15 mg / kg PO BD Duration : 3-6 months
16 Pancreatic abscess
Enterobacteriaeceae Enterococci Anaerobes
Imipenem 1gm with Cilastatin
IV TDS is the drug of choice Or Meropenem 2 gm IV TDS
+ Metronidazole 500 mg IV TDS
Duration : 10-14 days
Alternative/Remarks: Addition of cover for yeast: Fluconazole 800 mg IV loading
dose day 1, followed by 400 mg 2nd day onwards
17 Pancreatitis with
sepsis Enterobacteriaeceae P.aeruginosa (occ)
Enterococcus Bacteroides
Imipenem 1gm with Cilastatin IV TDS is the drug of choice
Or Meropenem 2 gm IV TDS +
Metronidazole 500 mg IV TDS
Duration : 10-14 days Addition of cover for yeast: Fluconazole 800 mg IV loading
dose day 1, followed by 400 mg 2nd day onwards
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9 .Infections of Urinary Tract
Sr. No
Conditions/ Expected
pathogens Revised MCGM recommendations
1. Cystitis
Most likely – E.coli Rare cause – Proteus spp, Klebsiella
spp
Nitrofurantoin 100 mg PO BD
Duration : 7 days Or Cotrimoxazole DS (800/160) PO OD Duration : 7 days
Alternative:
Ciprofloxacin 500 mg PO BD Or
Norfloxacin 400 mg PO BD
Duration: 3 days (E.coli, Kleb) Or
7 days (other susceptible organisms)
2 Complicated cystitis
(Patients with
structural
abnormalities, calculi,
diabetics, recurrent UTI)
Most likely – E.coli Rare cause –
Proteus spp, Klebsiella
spp
If patient is stable, same as above Duration: 14 days
If patient is unstable,
Inj Piperacillin + Tazobactam 4.5 gm IV TDS Alternative/Remarks: Culture mandatory.
If patient does not respond in 72 hrs, advise imaging , USG, CT
and adjust antibiotic as per culture sensitivity report.
3 Acute uncomplicated
Pyelonephritis E.coli,
Staphylococcus
saphrophyticus (in
sexually active young
women), Klebsiella
pneumoniae, Proteus
mirabilis
Piperacillin-Tazobactam 4.5 gm IV 8hrly OR (QID if
pseudomonas) Cefoperazone-Sulbactam 3gm IV 12hrly OR Amikacin 15-20mg/kg/d IM/IV OD (preferred if outpatient) or Gentamicin 4-7mg/kg/d IM/IV OD (preferred if outpatient) Duration 2 weeks
Monitor creatinine if on amino glycoside
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4 Complicated
Pyelonephritis Escherichia coli, Klebsiella pneumonia, Proteus mirabilis,
Pseudomonas
aeruginosa,
Enterococcus sp.
Frequently multi-drug
resistant organisms are
Piperacillin-Tazobactam 4.5 gm IV 6hrly
Cefoperazone-Sulbactam 3gm IV 12hrly OR Amikacin 15-20mg/kg/d IM/IV OD (preferred if outpatient) Gentamicin 4-7mg/kg/d IM/IV OD (preferred if outpatient) SECOND LINE
Meropenem 1gm IV 8hrly or Imipenem 1gm 8hrly In
Addition: *Ciprofloxacin 500mg BD or Levofloxacin 750 mg OD added
if pseudomonas *Switch as per culture
present
*Duration 2 weeks *Monitoring of creat if ag *Two agents if sepsis or MODS present
5 Acute Prostatitis
Enterobacteriaceae TMP-SMX 960 mg BD X 4-6 weeks Ciprofloxacin 500mg BD
or Levofloxacin 500mg OD 4-6 weeks Severe systemic symptoms -treat as pyelonephritis
6 Cathetar associated UTI • Sample collection
• Remove catheter and collect clean catch MSU
• Change PUC and collect sample from new catheter • Under all asepsis, puncture catheter with sterile
needle
• Treat as complicated pyelonephritis
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10. Plastic surgery and burns
Sr. No
Conditions/ Expected
Pathogens Revised MCGM recommendations
1. Maxillofacial injuries
(single uncomplicated
fractures)
At induction: Co-amoxiclav 1.2g IV OR Ceftriaxone 1g
IV Immediate post op: 6-8 hrs post induction dose:
Coamoxiclav 1.2g IV Post op: Tab Co-amoxiclav 625mg TDS for 5 days
2. Maxillofacial injuries
(complicated multiple
fractures, panfacial fractures)
At induction: Co-amoxiclav 1.2g IV OR Ceftriaxone 1g
IV Immediate post op: 6-8 hrs post induction dose:
Coamoxiclav 1.2g IV Late post op: IV antibiotic continued for 3 days Switch over to oral : Tab Co-amoxiclav 625mg TDS for
7 days
3. Clean surgery
Co-amoxiclav 1.2g IV OR Cefuroxime
Repeat dose if surgery extends beyond 6 hrs In
addition: Modify antibiotics as per culture and sensitivity report
4. Clean contaminated
wounds (debridement and
grafting, minor debridement, etc)
At induction: Co-amoxiclav 1.2g IV OR Ceftriaxone 1g
IV Immediate post op: 6-8 hrs post induction dose:
Coamoxiclav 1.2g IV Late post op: Tab Co-amoxiclav 625mg TDS for 5 to 7
days (till 1st dressing) In addition:
Modify antibiotics as per culture and sensitivity report
5. Dirty wounds (major debridement and
bone debridement),
major flap and free flap
surgeries
At induction: Co-amoxiclav 1.2g IV OR Ceftriaxone 1g IV or as per culture reports
Immediate post op: 6-8 hrs post induction dose:
Coamoxiclav 1.2g IV or as per culture reports Late
post op: IV antibiotic continued for 5 days Switch
over to Tab Co-amoxiclav for next 5 days or as per
culture reports In addition: Modify antibiotics as per culture and sensitivity report
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6 Burns (early excision
and grafting)
At induction: Piperacillin-Tazobactum 4.5 g IV OR
Meropenem 1g IV Immediate post op: 6-8 hrs post induction dose:
Piperacillin-Tazobactum 4.5 g IV OR Meropenem 1g IV Late post op: IV antibiotic continued for 5 to 7 days with
change as per culture reports / clinical response
May switch over to oral as per culture reports Antifungal Therapy – When extensive burns and patient not responding to
antibiotics o If hemodynamically stable: Fluconazole o If
hemodynamically unstable: Echinocandin
In addition:
-Antibiotic choices are dependent on the antibiogram of
the individual institution. -Surgical debridement as necessary. -Amphotericin B is toxic to all burn patient as renal system compromised, hence Caspofungin may be used
7 Burns (late grafting)
At induction: Co-amoxiclav 1.2g IV OR Ceftriaxone 1g
IV
Immediate post op: 6-8 hrs post induction dose:
Coamoxiclav 1.2g IV
Late post op: Tab Co-amoxiclav 625mg TDS for 5 to 7
days
In addition: -Antibiotic choices are dependent on the antibiogram of
the individual institution.
-Surgical debridement as necessary. -Amphotericin B is toxic to all burn patient as renal
system compromised, hence Caspofungin may be used
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11. Infections in Obstetrics and
Gynaecology
Sr.
No
Condition/ Expected
Pathogens
Revised MCGM recommendations
1 Vaginal discharge Trichomonal vaginitis Monilial vaginitis Bacterial vaginosis
Fluconazole 150 mg PO once and Secnidazole 2 g PO once (MDACS/NACO Green kit) Alternatives: Both sexual partners to be treated simultaneously. Both are category C, so withhold treatment until after first trimester,
unless urgent treatment is felt to be necessary Local treatment in the form of intravaginal agents such as creams or
suppositories as per requirement
2 Cervical discharge Chlamydia trachomatis
Cefixime 400 mg PO once Azithromycin 1 g PO once (MDACS/NACO Grey kit) Both sexual partners to be treated simultaneously.
3 Septic abortion, Bartholin's abscess, Chorioamnioitis, PPROM, PROM, Burst abdomen Severe PID Peritonitis Enterobacteriaeceae Enterococci Anaerobes
I.Co-amoxiclav1.2 g IV q12h X >7 d + Inj. Metronidazole 500 mg(100 cc) IV q8h X >7 d + Inj. Gentamicin 1.5 to 2 mg/kg loading dose, followed by 1 to 1.7
mg/kg IV or IM q8h X 5 d Or II. Ceftriaxone 1.5 gms IV q12h + Metronidazole 500 mg IV q8h + Amikacin 500 mg IV q12h Duration : 5 days
Alternatives/Remarks: Wound swab/ pus collected for culture sensitivity. Modify if required as per culture sensitivity result. Monitor renal function Consider Vancomycin or Clindamycin as per clinical condition
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4 PID: Mild C.trachomatis
N.gonorrhoea Mycoplasma Anaerobes G.vaginalis
Tab Cefixime 400mg PO once + Tab Metronidazole 400 mg PO TDS for 14 days + Cap Doxycycline100 mg PO BD for 14 days (MDACS/NACO yellow kit)
Alternatives: Contraindicated in pregnancy
5 Syphilis Refer to STD program guidelines
6 Tuberculosis in
pregnancy Please refer RNTCP guideline WHO has advocated that, all the first line drugs are safe in
pregnancy and can be used except streptomycin. SM causes
significant ototoxicity to the fetus (Pyrazinamide not
recommended by US FDA) 1. Mother and baby should stay together and the baby
should continue to breastfeed. 2. Pyridoxine supplementation is recommended for all
pregnant or breastfeeding women taking isoniazid as well as to
neonate who are being breast fed by mothers taking INH.
Remarks:
Very small chance of transmission of infection to fetus.
Late diagnosis can predispose to LBW, prematurity.
7 Influenza in pregnancy Oseltamivir 75 mg Oral BD for 5 days
In addition:
Nebulization with Zanamvir respules (2) 5 mg each, BD for 5 days
Remarks: 1. Tendency for severe including premature labor
&delivery. 2. Treatment should begin within 48 hrs of onset of
symptoms.
3. Higher doses commonly used in non pregnant population
(150 mg) are not recommended in pregnancy due to safety
concerns. 4. Chemoprophylaxis can be used in significant exposures. 5. Live (nasal Vaccine) is contraindicated in pregnancy.
Complications: -Direct fetal infection rare -Preterm delivery and pregnancy loss.
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8 Varicella >20 wks of gestation, presenting within 24 hours of the onset of
the rash, Acyclovir 800mg Oral 5 times a day IV acyclovir recommended for the treatment of severe
complications, > 24 hrs from the onset of rash, antivirals are not found to be
useful.
VZIG should be offered to susceptible women < 10 days of the
exposure. VZIG has no role in treatment once the rash appears.
The dose of VZIG is 125 units / 10kg not exceeding 625 units, IM Remarks:
Chickenpox during pregnancy does not justify termination
without prior prenatal diagnosis as only. A minority of fetuses infected develop fetal varicella syndrome.
9 Toxoplasmosis in
pregnancy <18 weeks gestation at diagnosis Spiramycin 1 gm Oral qid until 16-18 weeks/Pyrimathamine
+ sulphadizine. Alternate every two weeks
If PCR Positive - >18 weeks gestation and documented fetal infection by positive
amniotic fluid PCR. Pyremethamine 50 mg Oral BD x 2 days then 50 mg OD + Sulphadiazine 75 mg/kg Oral x 1 dose then 50mg/kg bd + Folinic Acid (10-20 mg Oral daily) for minimum of 4 weeks or
for duration of pregnancy.
10. Malaria in pregnancy As per national program
11. Mastitis without
abscess Amoxycillin clavulunate/Cephalexin 500 mg QID/ OR Ceftriaxone 2 gm OD OR MRSA- based on sensitivities Add
Clindamycin 300 QID or Vancomycin I gm IV 12 hourly /teicoplanin 12mg/kg IV 12
hourly x 3 doses followed by 6 once daily IV
12. Mastitis with abscess Drainage with antibiotic cover for MRSA
Clindamycin 300 QID or Vancomycin 15mg/kg IV 12 hourly (maximum 1gm 12
hourly)/teicoplanin 12mg/kg IV 12 hourly x 3 doses followed
by 6 mg once daily IV
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12. Pediatric infections
Sr.
No
Condition/ Expected
Pathogens
Revised MCGM recommendation
1. Tonsillitis/ Pharyngitis Grp
A beta
haemolytic
Streptococci
Amoxycillin (Oral) 40 mg/kg/day (<30 kg); 50 mg/kg/day
given TID, can be given BID (>30 kg) Duration : 10 days Alternatives Cefaclor (20-40 mg/kg/d in 3 divided doses) / Cephalexin (50 mg/kg/d in 3 divided doses)-
Erythromycin (40 mg/kg/day in 3 divided doses for 10 days)/
Azithromycin (12 mg/kg/day single dose for 5 days)
2. Otitis Media
Amoxicillin: 80-90 mg/kg per day OR
Co-amoxiclav: 90 mg/kg per day of Amoxicillin, with 6.4 mg/kg
per day of clavulanate in 3 divided doses Duration:7-10 days
Alternatives: Ceftriaxone IV: 1 or 3 days OR Azithromycin
Remarks: May require tympanocentesis
3. Sinusitis
Amoxicillin (oral: 45 mg/kg/day) or Co-amoxiclav (oral: 80-90 mg/kg/day of amoxicillin) if failure to
respond to amoxicillin in 72 hrs. Alternatives:
Trimethoprim-Sulfa-methoxazole (TMP 10 mg/kg/day and
SMX 50 mg/kg/day in 2 div doses) OR Azithromycin Remarks: Refer to ENT surgeon if no response
4. Pneumonia
Community
acquired Age 3 weeks to 3 months
IV Cefotaxime (150mg/kg/d) in 2-3 div doses
OR IV Ceftriaxone
(50-75mg/kg/day OD) for hospitalized patients
Duration : 10-14 days. Add erythromycin for chlamydia
Alternative: Coamoxyclav 100 mg/kg/day in two divided doses
Remarks: Amoxicillin (80-90 mg/kg/day oral) can be used in nonhospitalized
patients
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5. Pneumonia
Community
acquired
IV Cefotaxime (150mg/kg/d) in 2-3 div doses
OR IV Ceftriaxone (50-75mg/kg/day OD) for hospitalized patients
Age 4 months – 4
years
Duration: 10-14 days.
Add vancomycin or Clindamycin
if MRSA is the etiology
Alternatives: Co-amoxiclav / Cefuroxime axetil (150-200mg/kg/d in 3 div doses)
Remarks: Amoxicillin (80-90 mg/kg/day oral) can be used in
nonhospitalized patients
6. Pneumonia
Community
acquired Age
> 5 years
Above plus Add Azithromycin (for M.pneumoniae and C.pneumoniae) 12 mg/kg/day single dose for 5
days Duration : 5 days
Alternatives: Co-amoxiclav / Cefuroxime axetil PLUS Azithromycin
Remarks: Amoxicillin (80-90 mg/kg/day oral) can be used in nonhospitalized
patients PLUS Azithromycin
7. Empyema
I.V. Cefotaxime / Ceftriaxone(100 mg/kg/24 hr divided every
12 hr IV). Add I.V. Co-amoxiclav 100 mg/kg/day in two divided doses
Vancomycin (40-60 mg/kg/day in 4 div doses) or Linezolid (10mg/kg/dose 8-12 hrly) if MRSA is the aetiology .
Duration: 3-4 weeks Remarks: Thoraco-centesis/ ICD/ VATS as necessary
8. Acute epiglottitis
Ceftriaxone50-100 mg / kg / day BD
Or Cefotaxime50-100 mg / kg / day TDS
Duration : 7-10 days Alternative: Meropenem (IV 60 mg/kg/day in 3 div doses)
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9. Diphtheria
Erythromycin
(40-50 mg/kg/day divided every 6 hr by mouth [PO] max. 2 g/day)
Or Aqueous crystalline penicillin G (100,000-150,000 U/kg/day
divided every 6 hr IV or intramuscularly [IM]) Alternative:
Procaine penicillin (25,000-50,000 U/kg/day divided every 12 hr IM). Duration- 14 days
Remarks: Penicillins should be administered after test dose Specific antitoxin to be administered
10. Pertussis/
Whooping cough
Azithromycin: 10 mg/kg/day in a single dose for 5 days
Or Erythromycin (40-50 mg/kg/day in 4 divided doses for 14 days)
Alternative:
Clarithromycin (15 mg/kg/day in 2 divided doses for 7 days) Or TMP-SMZ (For infants aged ≥2 mo: TMP 8mg/kg/day plus SMZ
40 mg/kg/day in 2 divided doses for 14 days) Remarks: Same drugs are useful for prophylaxis
11. Diarrhoea
Viral Diarrhoea- No antibiotics required.
For Bacterial (E coli)- TMP 10 mg/kg/day and SMX 50
mg/kg/day BD× 5 days. For Salmonella- Treat similar to Shigella Remarks: Correct the dehydration. Add daily oral zinc for 14 days (10 mg/day for infants <6 mo of age and 20 mg/day for those
>6 mo)
12. Dysentery
Shigella dysenteriae
Ceftriaxone
50-100 mg/kg/day IV or IM, qd or BD× 7 days OR
Ampicillin PO, IV 50-100 mg/kg/day QDS× 7 days
Alternatives: TMP 10 mg/kg/day and SMX 50 mg/kg/day BD × 5 days.
Remarks: Nalidixic acid (50mg/kg/day in 4 div. doses)
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13. Cholera
Doxycycline (adults and older children): 300 mg given as a single
dose or Tetracycline 12.5 mg/kg/dose 4 times/day × 3 days (up to 500 mg
per dose × 3 days) Alternatives: Erythromycin 12.5 mg/kg/dose 4 times a day × 3 days (up to
250 mg 4 times a day × 3 days)
or TMP 10 mg/kg/day and SMX 50 mg/kg/day
BD × 5 days. Remarks: Rehydration. Add zinc for 14 days.
14. Giardiasis
Metronidazole PO 30-40 mg/kg/day in 3 div doses × 7 days
Alternatives: Furazolidone PO 25 mg/kg/day QDS × 5-7 days or
Albendazole PO 200 mg BD × 10 days
15. Intestinal amoebiasis
Metronidazole PO 30-40 mg/kg/day in 3 div doses × 7-10 days
16. Helminthic
infestations
Ascariasis- Albendazole (400 mg PO once, for all ages) or
Mebendazole (100 mg BD PO for 3 days or 500 mg PO once for
all ages),
OR Pyrantel pamoate (11 mg/kg PO once, maximum 1 g).
Trichuris- Mebendazole (100 mg BD PO for 3 days or 500 mg PO
once for all ages). A.duodenale- Albendazole (400 mg PO once, for all ages)
Alternatives: Ascariasis- Nitazoxanide (100 mg BD PO for 3 days for
children 1-3 yr of age and 200 mg BD PO for 3 days for children
4-11 yr. Trichuris- Albendazole (400 mg PO once for all ages)
or Nitazoxanide (100 mg BD PO for 3 days for children 1-3 yr of age,
200 mg BD PO for 3 days for children 4-11 yr of age A.duodenale- Mebendazole 100 mg BD PO for 3 days
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17. Enteric fever
Ceftriaxone: 75mg/kg/day in 2 divided doses
Duration : 10-14 days Or Cefotaxime: 80mg/kg/day
Duration : 10-14 days Or Fluoroquinolone, e.g., Ofloxacin (15 mg/kg/day in 2 div doses)
Or Ciprofloxacin (15-30 mg/kg/day in 2 div
doses) Duration: 5-7 days Alternative: Azithromycin: 20 mg/kg/day for 7 days or Cefixime 20 mg/kg/day in 2 div doses for 7-14 days.
18. Community acquired sepsis
Cefotaxime (200 mg/kg/24 hr, given every 6 hr) or Ceftriaxone (100 mg/kg/24 hr administered once per day or 50 mg/kg/dose, given every 12 hr). Add Amikacin (if necessary).
Add Vancomycin if resistant S.aureus or resistant S.pneumoniae
suspected. Duration : 14 days
19 UTI-
uncomplicated
TMP-SMX: 3- to 5-day course of therapy with
trimethoprimsulfamethoxazole (TMP-SMX) is effective against
most strains of E. coli. Or
Nitrofurantoin (5-7 mg/kg/24 hr in 3-4 divided doses) also effective (also
active against Klebsiella and Enterobacter). Duration : 7-10
days Alternative: Amoxicillin (50 mg/kg/24 hr) also is effective as initial treatment
Or Cefixime 8mg / kg / day BD
20. UTI-Complicated
Ceftriaxone (50-75 mg/kg/24 hr, not to exceed 2 g) or
Cefotaxime (100 mg/kg/24 hr), or
Ampicillin (100 mg/kg/24 hr) with an aminoglycoside such as Gentamicin (3-5 mg/kg/24 hr in 1-3 divided doses) Duration : 7-10 days
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21. Bacterial
meningitis
Cefotaxime 200 mg/kg/24 hr, given every 6 hr) or
Ceftriaxone- first dose 75 mg/kg/dose then followed by 100
mg/kg/24 hr administered once per day or 50 mg/kg/dose,
given every 12 hrs. Add Amikacin if necessary.
Add Vancomycin if resistant S. pneumoniae suspected. Duration- 1 to 4 weeks
22. Skin and Soft Tissue Infections
Cellulitis Carbuncle
Cloxacillin 50 – 100 mg / kg / day 6 hrly IV followed by oral.
Add Clindamycin 20 – 30 mg / kg / day 6 hrly or Vancomycin 40 mg / kg / day 6 hrly over 60 mins slowly if
necessary.
23. Bone and Joint Infections
Cloxacillin (100 mg/kg/24 hr divided QDS IV), plus
broadspectrum cephalosporin, such as Cefotaxime (150-
225 mg/kg/24 hr divided TDS IV). If methicillin-resistant Staphylococcus is suspected, Vancomycin is
substituted for Cloxacillin. Duration- 4 to 6 weeks
24. Infective
endocarditis prophylaxis
Amoxicillin (50 mg/kg 1 hr before the procedure)
Alternatives: Ampicillin (50 mg/kg 30 min before the procedure) OR
Ceftriaxone (50 mg/kg IM or IV)
25. Malaria
Refer to National and MCGM Guidelines
26. Leptospirosis
Parenteral Penicillin G (6-8 million U/m2/day divided every 4 hr
IV
Duration : 7 days
Alternative: Tetracycline (10-20 mg/kg/day divided every 6 hr PO or IV for 7
days) OR Oral amoxicillin
27. pH1N1
(pandemic influenza 2009)
Oseltamivir
< 15kg - 30 mg BD; > 15-23kg - 45 mg BD;
> 23-40 kg - 60 mg BD; > 40 kg - 75 mg BD Duration : 5 days
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28. Chicken pox
(Varicella zoster)
Oral therapy with acyclovir (20 mg/kg/dose, maximum 800
mg/dose) given as 4 doses/day for 5 days can be used to treat
uncomplicated varicella in children >12 mo of age with
chronic cutaneous or pulmonary disorders, corticosteroid
therapy, and long-term salicylate therapy. Alternatives:
Start preferably within 24 hr of the onset of the exanthem. IV
therapy is indicated for severe disease and for varicella in
immunocompromised patients (even if begun 72 hr after onset
of rash).
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13. Acute febrile illness
Sr. No
Conditions/
Expected
pathogens
Revised recommendations
1. Leptospirosis
L. icterohaemorrhagia complex
Adults: Doxycycline 100 mg twice a day for 10-14 days (contraindicated
in pregnancy) + Inj. Crystalline penicillin 20 lacs IU IV every 6 hourly after test
dose. (For the individuals who are allergic to penicillin group of drugs
following alternative regimes maybe used)
Ceftriaxone 1 gm IV x 6 hourly for 7 days OR Cefotaxime 1 gm IV x 6 hourly for 7 days OR
Erythromycin 500 mg IV x 6 hourly for 7 days
Remarks: Pregnant & lactating mothers should preferably be admitted and
treated as above (except for doxycycline as it is contraindicated in
pregnancy) If pregnant women cannot be admitted then they should be given
capsule ampicillin 500 mg every 6 hourly for 10 days
Children < 8 years Amoxycillin/ Ampicillin 30-50 mg/kg/day should be given in
divided doses for 7 days
Inj. Crystalline penicillin should be given 2–4 lacs IU/kg/ day for
7 days after test dose. (For individuals who are allergic to penicillin group of drugs
following alternative regimes may be used) Ceftriaxone 50-75 IV mg/kg/day for 7 days OR Cefotaxime 50-100 IV mg/kg/day for 7 days OR
Erythromycin 30-50mg/kg/day in divided dose for 7 days
Prophylaxis after wading through flood water: Doxycycline 100 mg BD
Duration: 2 days
2. Malaria Plasmodium spp
Refer to national treatment guidelines http://www.nvbdcp.gov.in/Doc/Diagnosis-Treatment-Malaria-2013.pdf
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14 PRE- OPERATIVE PROPHYLAXIS / THERAPY
▪ In patients with community / hospital acquired infection, collect appropriate specimen for culture
and susceptibility testing prior to administration of antibiotic.
▪ It is not recommended to collect specimen from healing wounds.
▪ Modify / De-escalate treatment as per microbiology report and clinical response
▪ Basic infection prevention and control strategies should be in place.
▪ Definitions :
a) Clean wound (Surgery) - An uninfected operative wound in which no inflammation is
encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered.
b)Clean contaminated - Operative wounds in which the respiratory, alimentary, genital, or
urinary tracts are entered under controlled conditions and without unusual contamination.
Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included
in this category provided no evidence of infection or major break in technique is encountered.
c) Contaminated - Includes open, fresh, accidental wounds. In addition, operations with gross
spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is
encountered are included in this category.
d)Dirty -Includes old traumatic wounds with retained or devitalized tissue and those that involve
existing clinical infection or perforated viscera.
References - 1. American Society of Health System Pharmacists (ASHP) 2013 Report 2. WHO
Safe Surgery 2009
Sr
No
Condition / Expected
pathogen
Antimicrobial of choice
Dose / Route / Frequency /
Duration
Alternatives /
Remarks
OPHTHALMOLOGY
1 Pre-operative Prophylaxis
Clean cases
Cataract, terygium, glaucoma,
strabismus, lid(entropion,
exotropion,ptosis), corneal
transplant
Moxifloxacin e/d, one drop, 6 times
previous day of surgery.
Betadine e/d pre-operative
2 Contaminated cases
Endopthalmitis, corneal ulcer,
post traumatic tear with
infection,intraocular foreign
body, lacrimal sac surgery,
dacrocystitis
Systemic Cefotaxime 1 gm IV TDS
Or Ceftriaxone 1.5 gm IV BD for 3
days prior to surgery, 7 days post
surgery
+
Topical moxifloxacin, one drop, 6
times previous day
3 Corneal foreign body Patch for 24 hrs for epithelisation
before increased cycloplegia
Antibiotic Chloramphenicol applicap
Next day: antibiotic drops
moxifloxacin/ gatifloxacin X 3 days
ENT
1 Pre op prophylaxis –
Major head and neck surgery
including implant surgeries
Inj Cefazolin /2 gms (IV)
1st dose at induction or
Inj Cefuroxime sodium1.5 gm (IV)
2nd dose within 24 hrs
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Sr
No
Condition / Expected
pathogen
Antimicrobial of choice
Dose / Route / Frequency /
Duration
Alternatives /
Remarks
GENERAL SURGERY / GI surgery
1 Clean surgery
Staph aureus,
Staph epidermidis
Cefazolin 2 gms IV
OR
Co-amoxiclav (Amoxycillin 2 g +
Clavulanic acid 125 mg) / IV
Total only 3 doses
If surgery beyond 4
hrs., give another
dose.
Post-surgery,
2 doses at 12 hrly
interval X 1 day
2
Clean contaminated
Uncomplicated cases (patient stable)
Appendix / gall bladder-
Co-amoxiclav IV 3 doses
Or
Ceftriaxone 1.5 gm IV BDX 5 days
Complicated cases -
Cefotaxime 1 gm / IV TDS
OR
Ceftriaxone 1.5 gm / IV BD
+
Amikacin 5 mg / kg OD
+
Metronidazole 500 mg TDS
OR in case of beta lactam allergy,
Aztreonam, 2g IV +
Amikacin 5 mg / kg OD
+
Metronidazole 500 mg TDS
For complicated
cholecystectomy,
cefaperazone +
sulbactam should be
the drug of choice as
it has the best biliary
penetration /
concentration.
3 Contaminated
Duodenal / Ileal perforation
(Patient stable)
Cefotaxime 1 gm IV
Or
Ceftriaxone
1.5 gmIV BD X 5 days
Patients with organ failure / sepsis /
In seriously ill / previous
hospitalization,
Piperacillin Tazobactam 4.5 gm
TDS
+ Amikacin 5 mg / kg OD
+ Metronidazole 500 mg QDS
5 days
4
Implants
(Gram pos cooci,
Enterobacteriaeceae)
Cefuroxime
1.5 gm / IV
If surgery beyond 4 hrs, give another
dose, then
BD X 5 days
OR
Cefazolin is preferred
over 2nd and 3rd gen
cephalosporins as
they are potent
inducers of ESBL.
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Sr
No
Condition / Expected
pathogen
Antimicrobial of choice
Dose / Route / Frequency /
Duration
Alternatives /
Remarks
Co-amoxiclav Amoxicillin 2 gm +
Clavulanic acid 125 mg / IV
If surgery beyond 2 hours , give
another dose. Then, BD X 5 days
5
Post-splenectomy - long term
prophylaxis
Enterobacteriaeceae
Anaerobes
2 weeks prior to elective
surgery,vaccinate for S.pneumoniae,
H.influenzae b and N.meningitidis.
Repeat Hib vaccine annually. +
Amoxicillin 500 mg PO OD
Duration : 2 years
CARDIAC SURGERY
1 CABG
Prophylactic antimicrobials:
Cefazolin 1 g IV. 60 min prior to
skin incision
Repeat the dose of 1 g every 3-4
hours as long as the surgical site is
open.
If high incidence of methicillin
resistant staphylococci (MRSA /
MRCoNS) is found (>20%) , then
Vancomycin 1 to 1.5 or 15mg/kg
administered slowly over 1 hour,
with completion within 1 hour of the
skin incision.
Thereafter, repeat dose of
Vancomycin of 7.5mg/kg may be
considered during cardiopulmonary
bypass.
Infection control measures to be
strengthened to bring down the
incidence.
Alternative treatment:
Cefuroxime
If patients allergic to
b-lactam antibiotics:
Vancomycin
Clindamycin
2 Other major cardiac surgery
Same as above
3 Paediatric Cardiac Surgery
Same as CABG, except the dose
Cefazolin: 30mg/kg
Vancomycin : 15 mg/kg
Gentamicin: 3 mg/kg
4
Pacemaker/ Defibrillator
Implantation
S. aureus
S. epidermidis
Gram Negative Bacilli
Cefazolin 1 g IV. 60 min prior to
skin incision
5 Cardiac Catheterization Not routinely
Antibiotic
prophylaxis is
indicated in patients
at high risk of
complications
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Sr
No
Condition / Expected
pathogen
Antimicrobial of choice
Dose / Route / Frequency /
Duration
Alternatives /
Remarks
secondary to Infective
Endocarditis
ORTHOPAEDICS
1 Clean Non Infected Cases
with minor implants
(K Wire etc./ No Implants)
S. aureus
Cefazolin 1 g IV. 60 min prior to
skin incision
Cefuroxime 1.5 g IV
one dose, one day
2nd and 3rd gen
cephalosporins are
potent inducers of
ESBL
2 Surgeries with major
implants
(including THR, TKR)
GNB, S. aureus
Cefuroxime 1.5 g IV BD
+ Amikacin 750 mg IV od before
surgery
Maximum continued till 2 days
3 Open Fractures Cefuroxime 1.5 g IV BD
+ Amikacin 750 mg IV od
+ Metronidazole 500 mg TDS
Continued for 7-10 days as per
wound healing status
Cefixime as
alternative for
cefuroxime
4 Closed Fractures
Nil
OBGY
1
Minor cases
S.aureus
Inj Co-amoxiclav 1.2 gm (IM/IV)
Single dose
30-60 mins before procedure /
incision
Cefazolin 1 g IV. 60
min prior to skin
incision
Single dose
2
Episiotomy
Enterobacteriaeceae,
Anaerobes
Inj. Co-amoxiclav 1.2 gm IV Single
dose ,
Followed by
625 mgTDS X 3 days.
3
Tubal ligation
S.aureus
GNB
Inj. Co-amoxiclav 1.2 gm IV Single
dose followed by oral
625 mg 8 hourly X 5 days.
4
Clean and Clean
Contaminated
S.aureus,
Other Gram positive cocci
Rarely
Gram negative bacilli
Inj Co-amoxiclav 1.2 gm 12
hourly(IV/IM) until orals started
625 mg TDS upto total 5 days
+
Metronidazole500 mg(100cc) IV
TDS x 5 days
+
Inj. Gentamicin 1.5 to 2 mg/kg
loading dose, followed by 1 to 1.7
mg/kg IV or IM every 8 hours x 3
days
5
Post operative wound gape
S.aureus,
Enterobacteriaeceae,
Anaerobes, Enterococci,
Inj Ceftriaxone 1gm IV BD X 5-7
days
+
Collect specimen for
culture sensitivity.
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Sr
No
Condition / Expected
pathogen
Antimicrobial of choice
Dose / Route / Frequency /
Duration
Alternatives /
Remarks
Other Gram positive cocci Inj Metronidazole500 mg IV TDS X
5-7 days
Change antibiotic
based on
microbiology report
as required.
NEUROSURGERY
1
Clean cases
Oral:
Amoxicillin 2 g (50 mg/kg) /
Cephalexin 2 g (50 mg/kg) /
Cefadroxil 2 g (56 mg/kg)
Single dose before procedure
Vancomycin 1g (20 mg/kg) IV (in
MRSA positive and penicillin
allergic patients)
For patients allergic
to penicillin
Clindamycin 600 mg
(20 mg/kg) /
Azithromycin 500 mg
(15 mg/kg) /
Clarithromycin 500
mg (15 mg/kg)
2
Surgery on contaminated
cases
Clindamycin 0.6 g IV 8 hrly +
Gentamicin 80 mg IV 8 hrly
Ampicillin 2g IV 6 hrly/ +
Gentamicin 80 mg IV 8 hrly +
Metronidazole 0.5g IV 8 hrly
Amoxicillin 1g + clavunate 0.2 g
IV 12 hrly
All given for 5 days
Cefazolin 1g IV 8
hrly + Vancomycin
1g IV 12 hrly if
MRSA prevalence
in cenre is high /
MRSA expected
PLASTIC SURGERY
1 Clean surgery
Cefazolin 2 g stat in clean surgery at
induction
Co-amoxiclav 1.2g
IV OR Ceftriaxone
1g IV
Immediate post op: 6-
8 hrs post induction
dose: Amoxclav 1.2g
IV
Late post op: Tab
amoxclav 625mg BD
for 5 to 7 days (till 1st
dressing)
2
Clean contaminated wounds
(debridement and grafting,
minor debridement, etc)
At induction: Co-amoxiclav 1.2g IV
OR Ceftriaxone 1g IV
Immediate post op: 6-8 hrs post
induction dose: Co-amoxiclav 1.2g
IV
Late post op:
Tab Co-amoxiclav 625mg BD for 5
to 7 days (till 1st dressing)
3
Dirty wounds
(major debridement and bone
debridement), major flap and
free flap surgeries
At induction: Co-amoxiclav 1.2g IV
OR Ceftriaxone 1g IV or as per
culture reports
Immediate post op: 6-8 hrs post
induction dose: Co-amoxiclav 1.2g
IV or as per culture reports
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Sr
No
Condition / Expected
pathogen
Antimicrobial of choice
Dose / Route / Frequency /
Duration
Alternatives /
Remarks
Late post op: IV antibiotic continued
for 5 days
Switch over to Tab Co-amoxiclav for
next 5 days or as per culture reports
4 Burns (early excision &
grafting)
At induction:
Piperacillin-Tazobactum 4.5 g IV
OR Meropenem 1g IV
Immediate post op: 6-8 hrs post
induction dose:
Piperacillin-Tazobactum 4.5 g IV
OR Meropenem 1g IV or as per
culture reports
Late post op: IV antibiotic continued
for 5 to 7 days with change as per
culture reports / clinical response
May switch over to oral as per
culture reports
5 Burns (late grafting) At induction: Co-amoxiclav 1.2g IV
OR Ceftriaxone 1g IV
Immediate post op: 6-8 hrs post
induction dose: Co-amoxiclav 1.2g
IV
Late post op: Tab Co-amoxiclav
625mg BD for 5 to 7 days
6 Maxillofacial injuries
(single uncomplicated
fractures)
At induction: Co-amoxiclav 1.2g IV
OR Ceftriaxone 1g IV
Immediate post op: 6-8 hrs post
induction dose: Co-amoxiclav 1.2g
IV
Post op: Tab Co-amoxiclav 625mg
BD for 5 days
7 Maxillofacial injuries
(complicated multiple
fractures, panfacial fractures)
At induction: Co-amoxiclav 1.2g IV
OR Ceftriaxone 1g IV
Immediate post op: 6-8 hrs post
induction dose: Co-amoxiclav 1.2g
IV
Late post op: IV antibiotic continued
for 3 days
Switch over to oral :
Tab Co-amoxiclav 625mg BD for 7
days
8 Local anaesthesia cases in
minor OT
No antibiotics
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Paediatric Surgery
SR.
No. CONDITION
LIKELY
ETIOLOGY
TREATMENT
Drug / Dose / Duration /
Route
ALTERNATIVE
TREATMENT /
REMARKS
1 Clean Surgery (Pre-operative prophylaxis)
a Hernia
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
No antibiotic required
If to be given, then
Inj. Cefazolin 30 mg/kg IV
single dose
Laparoscopic herniotomy –
single shot of antibiotic
(Cefazolin)
b Hydrocoele
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria
No antibiotic required
unless the patient is
immunocompromised.
Inj. Cefazolin 30 mg/kg IV
single dose
c Orchiopexy
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Inj. Cefazolin 30 mg/kg IV
single dose or
Inj. Ceftriaxone 50 mg/kg
single dose
d
Cyst Excision &
sinuses in the
neck
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
No antibiotic required
unless 20 infection
If infection, then
Inj. Cefazolin 30 mg/kg IV 8
hourly for 3 days
e Circumcision
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
No antibiotic required
unless 20 infection
If infection, then
Inj. Cefazolin 30 mg/kg IV 8
hourly for 3 days
2 Clean Contaminated Surgery(Pre-operative prophylaxis)
a
Myelo-
meningocoele
Repair
S.epidermidis
S. aureus
Entero-
bacteriaeceae
Inj. Ceftriaxone 100 mg / kg
/ d, q12h
+
Inj. Metronidazole 30 mg/kg
/d, q6h
+
Inj amikacin
Duration : 5 days minimum
Inj. Clindamycin 20 mg/kg i.v.
8 hourly
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SR.
No. CONDITION
LIKELY
ETIOLOGY
TREATMENT
Drug / Dose / Duration /
Route
ALTERNATIVE
TREATMENT /
REMARKS
Or
Inj. Cefazolin 30 mg /kg i.v.
8 hourly
+ Inj. Metronidazole 30 mg /
kg /d, q6h
+ Inj Amikacin
Or
Inj Meropenem 20 -40 mg /
kg /dose thrice daily
Duration : 10-14 days (with
CSF leakage)
b Cystoscopy
S. aureus,
Entero-
bacteriaeceae
Inj. Ceftriaxone 100 mg / kg
/ d, q12h
Or
Inj. Cefazolin 30 mg /kg i.v.
8 hourly
+ Inj. Amikacin 15mg/kg/d,
q8h
Duration
1-3days if no UTI
Or
5-7 days if febrile UTI
Antibiotic to be directed as
per pre-op urine culture
sensitivity report.
c Thoracotomy (for
decortication)
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
antibiotic as per culture
sensitivity for 7-10 days
d Thoracotomy
(other indications)
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
Inj. Ceftriaxone 100 mg / kg
/d, q12h
± Amikacin
± metronidazole
Or
Inj. Cefazolin 30mg/kg i.v. 8
hourly
+amikacin
± metronidazole
Duration - 3-5 days
e Laparotomy
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
Inj. Cefazolin 30 mg / kg i.v.
8 hourly
+ Inj Amikacin
+ Inj. Metronidazole 30 mg /
kg / d, q6h
Duration : 3-5days
Or
Duration and antibiotic depends
on indication and surgery done
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SR.
No. CONDITION
LIKELY
ETIOLOGY
TREATMENT
Drug / Dose / Duration /
Route
ALTERNATIVE
TREATMENT /
REMARKS
Anaerobes Ceftriaxone /
Ceftazidime + Amikacin +
Metronidazole x 5 days
Or
Neonates - meropenem
f Laparoscopy
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
Anaerobes
Inj. Cefazolin 30 mg / kg i.v.
8 hourly + Inj Amikacin
± Inj. metronidazole 30 mg /
kg /d, q6h for 3-5 days
Or
1 dose for diagnostic
Laparoscopy
Inj. Ceftriaxone 100 mg / kg
i.v. 8 hourly
+ Inj. Metronidazole 30 mg /
kg / d, q6h – 1-5 for
appendicectomy and 5 days
for resection anastomosis
Same as above
g Thoracoscopy
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
CDH –
a. off ventilator –
Ceftriaxone or ceftazidime
Duration : 3 days
b. On ventilator –
Meropenem
or Imipenem + cilastatin
Duration : 7 days
Same as above
Antibiotics according to ICU
organisms in different hospitals
maybe needed.
h Hypospadias
S.epidermidis
S. aureus
Streptococcus,
Coryne-
bacteria,
Entero-
bacteriaeceae
Inj. Cefazolin 30 mg /kg i.v.
8 hourly
+ Inj. Metronidazole 30 mg /
kg /d, q6h
or
Inj. Ceftriaxone 100 mg/kg
i.v. 8 hourly
+ Inj. Metronidazole 30 mg /
kg /d, q6h
IV amoxyclavulanic acid 12.5
mg/kg/dose twice day of
amoxicillin for 1-3 days
i VP shunt Insertion
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Ceftriaxone (double dose ) +
amikacin
Duration : 5 days
Depending on CSF culture
sensitivity reports
j TEF repair
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Inj. Ceftriaxone 100mg/kg
i.v. 8 hourly + Inj amikacin
+Inj. metronidazole 30
(mg/kg)/d, q6h for 7 days
or
meropenem
Imipenem + cilastatin or
colistin for 7days for bad
patients/ on ventilator/ delayed
presentation
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SR.
No. CONDITION
LIKELY
ETIOLOGY
TREATMENT
Drug / Dose / Duration /
Route
ALTERNATIVE
TREATMENT /
REMARKS
Anaerobes Piperacillin + tazobactam
90mg/kg/dose four times a
day + metro
Antibiotics according to ICU
organisms in different hospitals
maybe needed.
k Appendicectomy
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Ceftriaxone or Ceftazidime –
single shot
OR
Co-amoxiclav-single shot
Complicated appendicitis -
Ceftriaxone ± amikacin +
metronidazole
Duration :3-7 days
Inj. Clindamycin 20 mg /kg i.v.
8 hourly
+ Gentamicin, 3 mg per kg
or Moxifloxacin 10 mg/kg
+ Metronidazole
Duration :5-7days
l Choledochal Cyst
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Ceftriaxone or Cefoperazone
± amikacin
+ Metronidazle
Duration : 7 days
Same as above
m Cholecystectomy
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Inj. Ceftriaxone
± Co-amoxiclav single shot
Or
Cefoperazone + Amikacin +
Metronidazole if sick child
Same as above
n Abdominal pull
through
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Ceftriaxone or Ceftazidime
± amikacin
+ Metronidazole
Or
Cefazolin 30 mg /kg i.v. 8
hourly
+ Amikacin
+ Metronidazole 30 mg / kg
/d, q6h .
Duration : 5-7 days
Same as above
o ASARP
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Ceftriaxone or Ceftazidime
± Amikacin
+ Metro
Or
Cefazolin 30 mg/kg i.v. 8
hourly
+Amikacin
+ metronidazole 30 mg / kg
/d, q6h
Duration : 5-7days
Same as above
p PSARP
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Ceftriaxone or ceftazidime ±
amikacin + metro
OR
Cefazolin 30 mg/kg i.v. 8
hourly
Same as above
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SR.
No. CONDITION
LIKELY
ETIOLOGY
TREATMENT
Drug / Dose / Duration /
Route
ALTERNATIVE
TREATMENT /
REMARKS
Anaerobes + Amikacin
+ Metronidazole 30 mg / kg
/d, q6h are used.
Duration : 3-5days
q Biliary atresia
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Ceftriaxone or Cefoperazone
± Amikacin
+ Metronidazole
Duration : 7 days
Same as above
r
Hepatic Resection
& other Hepato
Biliary Conditions
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Piperacillin–tazobactam,
Infants 2–9 mo: 80 mg/kg of
the piperacillin component,
Children >9 mo and ≤40 kg:
100 mg/kg of the piperacillin
component 2 hrly
Or
Cefoperazone /Ceftriaxone +
metronidazole
Duration : 5 days
Same as above
3 Contaminated (Empiric Therapy)
a
Incision &
drainage of
Abscesses
Superficial
abscesses
S.aureus
(mostly),
S.pyogenes,
E.coli
cloxacillin 25-50mg/kg in 4
divided doses for 5-10 days
Cephalexin / co-amoxyclav for
10-14 days
b
Deep intra-
abdominal
abscesses
S.aureus
(mostly),
S.pyogenes,
E.coli
Ceftazidime or ceftriaxone
+ amikacin
+ metro
Duration : 5-7days
± chloroquine
x 5-7 days
Surgical drainage followed by
placement of indwelling drains
is the procedure of choice.
c Stoma formation
S.epidermidis
S. aureus
Streptococcus,
Entero-
bacteriaeceae
Anaerobes
Ceftriaxone/ ceftazidime +
metronidazole
Or
Ampicillin- sulbactam 50
mg/kg of the ampicillin
component
+ Gentamicin 2.5mg/kg i.v. 8
hourly
+Metronidazole 15mg/kg i.v.
8 hourly
Duration – 3days
If neonate – 5 days
May need to be stepped up if
enterocolitis, sick child, sepsis
or depending on icu flora
1.
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SR.
No. CONDITION
LIKELY
ETIOLOGY
TREATMENT
Drug / Dose / Duration /
Route
ALTERNATIVE
TREATMENT /
REMARKS
c Fistulectomies
S.epidermidis
S. aureus
Streptococcus,
Entero-
Bacteriaeceae
Enterococci
Anaerobes
2. – oral cefazolin +
metronidazole for 3 days
cefazolin 30mg/kg i.v. 8
hourly + metronidazole 30
(mg/kg)/d, q6h or 40 mg/kg
2 hrly
or
ampicillin–sulbactam 50
mg/kg of the ampicillin
component or ceftriaxone +
metronidazole
Clindamycin 20mg/kg i.v. q8h
+ Gentamicin, 3 mg per kg
or fluoroquinolone
(moxifloxacin 10 mg/kg)
Or
Metronidazole +
aminoglycoside or
fluoroquinolone
d Rectal Polyp
Excision
S.epidermidis
S. aureus
Streptococcus,
Entero-
Bacteriaeceae
Enterococci
Anaerobes
cefazolin 30mg/kg i.v. q8h
+ metronidazole 30 mg/kg /d,
q6h
Or
ampicillin–sulbactam 50
mg/kg of the ampicillin
component
Or ceftriaxone +
metronidazole
Duration – 1-3 days
Same as above
e Debridement of
burns
S. aureus
Entero-
Bacteriaeceae
Pseudomonas
Piperacillin–tazobactam,
Infants 2–9 mo: 80 mg/kg of
the piperacillin component,
Children >9 mo and ≤40 kg:
100 mg/kg of the piperacillin
component 2 hrly + metro for
5-7 days
or cefotaxime 50 mg/kg 3
hrly + ampicillin 50 mg/kg 2
hrly for 5-7 days
as per tissue culture sensitivity
Topical therapy is often applied
to prevent infection and to treat
ongoing infections or used as an
adjunct to surgical treatment
and systemic antibiotics.
Topical silver nitrate +
gentamicin are preferred
f Resection &
anastomosis
S.epidermidis
S. aureus
Streptococcus,
Entero-
Bacteriaeceae
Enterococci
Anaerobes
Ceftriaxone /
ceftazidime+amikacin +
metro x 5 days
Or
Neonates – meropenem
/colistin
x 5-7 days
Clindamycin 20mg/kg i.v. 8
hourly + aminoglycoside
(gentamicin, 3 mg per kg)
or fluoroquinolone
(moxifloxacin 10 mg/kg) +
Metronidazole +
aminoglycoside
3. – as per requirement x 5-
7days
g Perforative
peritonitis
Enterococci
Entero-
Bacteriaeceae
Anaerobes
Ceftriaxone /
ceftazidime+amikacin +
metro x 5 days
OR
as per requirement
In pediatric surgery
conditions , in neonates for
surgical intervention –
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SR.
No. CONDITION
LIKELY
ETIOLOGY
TREATMENT
Drug / Dose / Duration /
Route
ALTERNATIVE
TREATMENT /
REMARKS
Neonates – meropenem
/colistin
x 5-7 days
meropenem or imipenem +
cilastatin are required
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